Denial Management Handbook

Table of Contents
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NO TABLE OF CONTENTS ENTRIES FOUND.

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1 Preamble

1.1.1 Objective
Purpose of this handbook is to help the associates address the denials in their AR inventory with the available
resources to the maximum extent possible without having to call the payer.

1.1.2 Target Audience

Associates working in the 01 to 10 shift. This would also assist the Day AR associates in resolving accounts
without having to handoff to the Callers to a large extent.

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2 Denial Management
2.1.1 Definition
Denial of a claim is the refusal of an insurance company or carrier to honor a request by an individual, or his or her
provider, to pay for a health care services obtained from a health care professional.

2.1.2 Common Denial Types

Soft Denial
A temporary denial that has the potential to be paid if the provider takes effective follow-up action.
 Appeal not required, Examples:
o Pending receipt medical records
o Denied due to missing or inaccurate information
o Coding or charge issues
o Pending itemized bill
o Pending receipt of invoice

Hard Denial
A denial that results in lost or written-off revenue.
 Appeal is required, Examples:
o No pre-authorization
o Not a covered service
o Bundling
o Untimely filing

Preventable or Avoidable Denial

A hard denial resulting from action or inaction on the part of the provider of services
 Usually involve elective services that could have been delayed or deferred
 Account for about 90 percent of denials, Examples:
o Registration inaccuracies/Ineligible for insurance
o Invalid codes, Medical necessity
o Credentialing

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Clinical Denial
Denials of payment on the basis of medical necessity, length of stay or level of care.
 May be concurrent (while patient is still in-house)
 or retrospective (after the patient is discharged)
 Typically begin as a soft denial
o Delay of payment where further medical or clinical clarification may be required

Technical or Administrative Denial

A denial in which the payer has notified the provider, by way of remittance advice, with specific information
describing why the claim or item was denied.
 Typically done via remark code or reason code
 Includes delay of payment where additional documentation is needed
o Coding clarification
o Requests for medical records
o Itemized bills

The majority are administrative in nature

 Missing information
 Inaccurate information
 Time span issues (dates of services, authorizations)
 Ineligible patient, service or provider
 Coding errors with diagnosis, patient identifier #, NPI (provider identifier), procedure code

2.1.3 Reason for Denials

 Medical necessity
 Missing or invalid CPT or HCPCS code submitted
 Incorrect patient identifier information submitted
 Spelling of name, DOB, subscriber number missing / invalid, insured group number missing /
invalid
 Procedure/surgery requires prior authorization or precertification
 Place of service does not match surgery/procedure performed
 Claim submitted for non-covered service

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